Francisco Goiri Madrid
Madrid
Updated Wednesday, March 6, 2024-02:07
Health The Economic and Social Council warns that the personnel crisis of the National Health System "requires priority attention"
Health The Primary Care crisis has a name and surname: "I can't take it anymore. I'm hanging up my robe"
Medical guards yes or medical guards no?
Exist, the guards have to exist.
Or, at least, a model that guarantees continued care, because permanent health care for the patient is an inherent requirement of the medical profession.
Another thing is how that attention is provided, how the work is organized, with how many employees... and how it is remunerated.
Let's rewind, then.
Is there an alternative to 24-hour medical guard?
Can the SNS assume this alternative organizationally and economically?
So untimely was the statement by the Minister of Health,
Mónica García
, that her intention was to end the 24-hour guards this term, "that there
are already several CCAAs that have told her to step on the brakes and not jump in
. The The matter has so much substance that just mentioning it makes the counselors' hair stand on end," says
Vicente Matas
, former national member of the Collegiate Medical Organization (OMC) and coordinator of the
Study Center of the Medical Union of Granada (Simeg)
.
Why is there so much regional agitation?
Because
it is the counselors - Matas recalls - who pay the doctor
, and they do not know if their coffers would support the expenditure necessary to articulate a viable alternative to the 24-hour guard.
To begin with,
many more doctors are needed
("the workforce would have to be increased by a third," Matas ventures), to embrace a shift system similar to that of Nursing staff and guarantee full coverage.
Secondly,
an alternative remuneration model
must be articulated that compensates for the salary loss derived from ending the guards, and that, at the same time, pays for the new shift system (night and shift bonuses, extra weekend remuneration and festive).
"In Nursing, the
on-call
concept only exists in primary school; in hospitals, they work their ordinary day, in morning, afternoon or night shifts, and they charge a bonus for nights and/or holidays," recalls the coordinator of the Study Center.
"Working in shifts similar to Nursing would require expanding the medical workforce by a third"
Vicente Matas, former national member of the Collegiate Medical Organization (OMC)
In the case of doctors - continues Matas, didactic -, "the on-call hour is, by concept, comparable to the overtime in other sectors", because it is done after the ordinary day (in 17-hour shifts), and on holidays and weekends 24 hours a day.
That's where the similarities ended
, adds Matas, "because on-call hours are mandatory for most doctors, they do not have the limit of 80 hours per year of overtime and they are paid well below these."
Overtime is generally paid at 175% of ordinary hours in any sector, and on-call hours are below the price of ordinary hours.
They are "mandatory for most doctors," says Matas.
Unless they have already turned 55 years of age, clarifies
Tomás Toranzo
, national president of CESM, because, in that case, they are volunteers in all communities.
In theory
.
According to the leader of the union with the most weight among Spanish doctors, this voluntariness is the first thing that is not fulfilled: "Neither the voluntariness nor the commitment to offer the doctor who decides not to do on-call
compensatory (and voluntary) modules of activity
, to avoid the retributive loss that not doing them implies".
Overtime is paid at 175% of ordinary hours;
the one on duty is worth less than the ordinary one and the Treasury takes 45%
Because on-calls are a substantial part of the doctor's payroll.
"They help you pay the mortgage, the children's studies, fill the refrigerator... those things. Eliminating them would mean a very large loss..., and unaffordable,
if the base salary is not substantially increased
," graphically summarizes the former member of the WTO.
HOW IS THE 'SUDOKU' COMPLEX SOLVED?
Deciding what percentage of the monthly payroll exactly the on-calls represent is not an easy task, due to the enormous variability in remuneration between autonomies, the disparity in the number of on-calls by specialties and services, and the salary differences that mark the doctor's professional career.
Even so, the Study Center directed by Matas has tried, based on
an average professional profile
: physician in the middle of his career, 40 years or older, tenured position, five three-year terms, earns the 2nd level of professional career and stands guard.
Specifically,
50 hours of on-call duty per month
: 24 of them on holidays and Saturdays (24-hour on-call, therefore) and the remaining 26 hours on a weekday.
With this
template
and the official salaries of the 18 health services in 2023, it is possible to gauge
how much money guards approximately represent
in a salary
ecosystem
as disparate as healthcare.
In 2023, a
typical doctor
with the socio-labor characteristics proposed by the Study Center directed by Matas earned an average of 3,277 net euros per month, without on-call, and his salary rose to exactly
831 net euros per month
, with 50 hours of on-call per month.
In other words,
guards represent 20.22% of a specialist's monthly net salary
.
"If we change the name of the guard, but the doctor has to work the same hours, it is of no use"
Tomás Toranzo, national president of CESM
This difference of more than 800 euros net between doing on-call and not doing them is maintained (euro up, euro down) throughout the doctor's entire professional career, and is much greater if the gross monthly salary (
1,439 euros) is used as a reference.
of difference, in the case of a physician in the middle of his career)
.
After a full year of work, a specialist who does 50 hours a month on call charges
9,676 net euros more
(17,188 gross) than another colleague who does none.
The salary difference of more than 800 euros net per month
is also downward,
because "there are many doctors who work significantly more hours on call in a month than the 50 that we have taken as a reference, especially in certain specialties, services and centers," emphasizes Matas.
In one year, a doctor who does 50 hours of on-call per month would earn 9,676 net euros more than another who does not do any.
For this reason, and because
not all autonomies pay the same for guard duty
: welcome to one of the most flagrant examples of pay inequality in the health sector..., and there are many.
In 2023, a SNS doctor charged
an average of 15.41 euros net per hour of on-call work on a weekday
(27.26 gross), but it is not the same to do an on-call in Ceuta and Melilla or Murcia (18.96 and 17. 01 net euros per hour of on-call, respectively) than doing it in the Canary Islands, the community that paid its doctors the worst in 2023 for this concept (12.23 net euros per hour).
On holidays, the SNS average was 16.87 euros net (29.89 gross per hour), the maximum was set, again, by Ceuta and Melilla, with 19.43 net, and the minimum was Madrid ( 13.99).
In short, even though it is important throughout the SNS,
a hypothetical abolition of guards would be more burdensome for the specialists in Ceuta and Melilla or Murcia than for those in the Canary Islands or Madrid
.
How much does the Treasury take?
From the words of Vicente Matas it is deduced that both the central Administration and the CCAA also have reasons to be reluctant to change.
The coordinator of the Simeg Study Center argues that the guard model
is very good for the SNS... and the Ministry of Finance
.
To the first, "because it guarantees continuity of care, accessibility and its sustainability with additional and mandatory work hours that are paid below the ordinary hour, and that, in general, do not count as time worked:
a 7-day day is counted the same. hours than another 24
".
They are also great for the public coffers, because the guards "are income that, generally, is above the maximum contribution base and does not count in social security. Now, the doctor's withholding of the pension is increased by 2 or 3 points. IRPF of the entire payroll and
the Treasury takes practically 45% of the gross amount of the hour on duty
," adds Matas.
Can the SNS, then, eliminate 24-hour on-call hours and propose an alternative model that guarantees continuous care and does not entail a reduction in remuneration for the doctor?
Can this legislature also do it, as the minister suggests?
Toranzo's response is clear:
"With the human resources and financing that the SNS currently has, it is unfeasible
. "
The nuance comes later: "A serious and very conscientious analysis is needed. By CCAA, by areas within each community, by health centers, hospitals, services and specialties. We are talking about a model that guarantees 24-hour assistance, with full coverage of all schedules, a more rational organization, and that does not translate into loss of pay, and that is not done in a legislature. If they are going to change the name of the guard, but the doctor has to work the same hours, no is of no use."
AN IMMEDIATE GOODBYE TO THE GUARDS: NO, BUT YES IN A LEGISLATURE
Sergio García Vicente
, member of the board of directors of the
Health Economics Association (AES)
, adds that "
from today to tomorrow, impossible, but in a legislature it is feasible
: we have the information and the forum to do it, too. called the Interterritorial Council (IC) and we are not using it politically. That is the scenario to make
an adjusted forecast, coordinated planning and effective execution
."
And all these syntagms are summarized, according to him, in
a basic principle
: assess the portfolio of services you have in each place and determine what you really need.
In short, organize
.
"If my son falls and suffers a head injury, I am clear that I would want to take him to the Niño Jesús Hospital, if I live in Madrid; to Sant Joan de Déu, if I am in Barcelona, or to La Fe, if I live in Valencia. To no other In these cases, doesn't it seem more sensible
to concentrate resources and specialists
in those centers than to disperse them in other hospitals
of the same autonomy whose demand for care is lower?" he asks.
"We have the data and quick access to it, we have the law and we have the Interterritorial Council. We just need to want to do it"
Sergio García Vicente, member of the board of directors of the Health Economics Association (AES)
As Toranzo said, that means analyzing case by case, but García Vicente insists that "we have the data and the possibility of accessing it quickly, we have the legislative tool [the
General Health Law
] and we have the forum to do it [the IC ] The only thing missing is
political will and overcoming the reluctance
, which there is, of unions, societies, professional organizations...".
Tamara Contreras
, the intensivist from Menorca who has promoted
a campaign on
Change.org
to end the 24-hour guards
, which has already garnered more than 80,000 signatures and which led the minister to
enter into the field
of this issue, agrees with the Health economist in the
reluctance
chapter , and lowers them even further to the ground, because he assures that his search for support
has already earned him the distrust of many colleagues
, "due to the possible loss of remuneration, of course, but also due to inertia inherited. I am 42 years old and I have been listening to the same discourse for many years:
this has always been like this and it is not going to change
, so you grow up with it and end up internalizing it as if it were a dogma.
Fortunately, he adds, "the new generations of specialists are not willing to continue with this pace of life, they support their rejection of marathon days with
studies of danger based on scientific evidence
and, increasingly, they choose the specialty they are going to pursue." in the MIR based on their vocation, but also on the estimated quality of life".
García Vicente,
fellowship
at
Baylor College of Medicine
(Houston), believes that the most evident proof of reluctance to change (political and/or professional) is that
the alternatives that have been tested in Spain at the
meso
level are not allowed to
breathe
. , "or that they are aborted when the political color changes, whatever it may be."
He cites the example of the
Valencia General Hospital
, "which once established a work organization with 12-hour medical shifts. The experience was good, it worked and people were happy, but in 2016, after the change of government in the community, was suppressed. How are we going to gauge the viability of an alternative to the current system of work organization if the history we have to do so does not go beyond the 4 years that a legislature lasts or, at most, the 8 years that make two?"
THE SECRET IS IN FLEXIBILITY
The mentality of the new generations, to which Contreras referred, and
the "unstoppable" feminization of the medical and nursing professions
imply, according to García Vicente, organizational flexibility, "for the system, but also for the professionals who practice in it. That "It is a debate, directly related to the organization of work, that we do not address seriously and that, if we are careless, will end up overwhelming us."
"There are maternity hospitals that do not handle 200 deliveries a year. Isn't it better to concentrate specialists where they are needed?"
There are maternity hospitals, he says, that do not produce 200 births a year, "when, perhaps, in a neighboring area, there is another hospital that cannot cope with the human resources it has. Isn't it more logical to focus resources on this Lastly? Does it make sense for a cardiologist, a neurologist or a rheumatologist to enter the weekend shift in centers with low demand for care, or is it more rational
for them to move to other centers that need reinforcements
and the shifts be organized there ?
From his basic training as a family doctor, García Vicente perfectly understands the specialist's fear of seeing his payroll diminish if the guards disappear, and he does not avoid the debate: rather than increasing the base salary, he proposes that "
the bonuses for night shifts, shift work and even on weekends increase by an amount significant enough
for the doctor to be compensated for working shifts.
The promoter of the collection of signatures understands the doubts that the review of the current model may raise, but "
those doubts cannot be an excuse for inaction
. Many countries around us have already adopted a shift system, and it works, and not even here We have not even begun to seriously analyze viable alternatives to a model that is more than half a century old and is obsolete. If we can, at least, achieve
a detailed analysis of the needs and resources community by community
, we will have taken the first step "concludes the intensivist.